WHEN IS IT MORALLY ACCEPTABLE TO FORGO LIFE-SUSTAINING TREATMENTS?  

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One day, I received an emergency call from a hospital for a patient who was just admitted to the ICU.  The caller calmly and politely asked for my immediate presence, because the patient was in an extremely critical condition. The family was in deep crisis.

Upon entering the room, I saw Larry (not his real name) who was standing at the bedside of the patient–his wife, Mary (not her real name). Larry told me that they were walking that morning at their favorite park on the beach. It was a gorgeous sunny day with clear light blue skies painting the horizon. The wind was still.

After walking for a couple of miles, Mary started to feel numb and with the onset of a severe headache. She had not experienced this sensation and pain before in her life. She collapsed and became unconscious after a couple of minutes.  Larry called 911, and Mary was immediately brought to the hospital.  After a series of tests, it was revealed that she had a rare case of a brain aneurysm. She was confined to the ICU and was intubated and attached to a mechanical ventilator. She was also hooked up to different types of monitoring devices and was administered IV fluids and feeding tubes.

A comprehensive assessment of Mary’s condition was conducted by two neurologists on staff.  Tests that included CT and MRI scans revealed a severe form of an aneurysm located at the innermost part of the brain. It was inoperable. The doctors confirmed that recovery is no longer possible.  At that time, any treatments would be considered futile (of no benefit or hope for recovery).  Doctors told Larry that they had done their best and had carried out all available procedures to save her life.

That was a distressing development.  No words could describe the sadness felt by the family as they listened to the words of the doctor.  Mary’s husband and children were not ready to face this tragic reality. They struggled with the uncertainties and dilemma of what to do and how to proceed with treatments. Are we going to remove the ventilator?  If so, when? Will we wait for the patient’s heart to stop beating before removing the ventilator and stopping all treatments?

 The principle of ordinary and extraordinary means addresses confusion concerning forgoing life-sustaining measures.

The Catholic Church uses the principle of “ordinary and extraordinary measures” or “proportionate and disproportionate means”  to shed light on the moral acceptability of withdrawing or withholding life support and other medical treatments. The principle of ordinary and extraordinary measures was developed and used by theologians many centuries ago to understand whether a refusal to accept a life-sustaining treatment in certain situations would constitute a failure in the duty to preserve a person’s life.[1] The terms “ordinary and extraordinary means” do not pertain to the level of sophistication of interventions or the technology being used.

Many people may find the application of ordinary or extraordinary means less clear because of the vagueness of the terms, ordinary and extraordinary, as well as the rapid medical advances in the treatment of various illnesses.  Modern medical technology is able to treat many illnesses, which are considered untreatable in the past.  What used to be considered extraordinary intervention has now become accepted standard medical protocol, thus becomes an ordinary intervention. These are the reasons why some people refer to extraordinary measures as disproportionate and ordinary measures as proportionate means.

The principle of ordinary and extraordinary means still holds good even in the midst of medical advancements.  The application of this principle is not based on the patient’s overall condition and the burdens and benefits involved in the application of a certain medical procedure. The physician, patient (if able) and family members work closely to determine the illness or pathology, prognosis, benefits, and risks of the proposed treatment, and the financial expense that affect the family and the community at large.

Ordinary or proportionate means of medical intervention are those that offer a reasonable hope of recovery to patients without excessive expense, pain, or burden. Extraordinary means refer to those interventions that offer extremely little reasonable hope of benefit and would involve excessive burden to the patients and families.[2] An excessive burden refers to something that is out of all proportion and imposes an undue hardship on the subject’s life.  Moreover, excessive burden also refers to costly treatments that severely imperils the financial security of the subject, the family or the community. [3]       

A person does not need to seek all medical means to treat a serious illness if there is scarce hope for cure and recovery or if the procedure is excessively taxing. The Catechism of the Catholic Church states:

2278: Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of “over-zealous” treatment. Here, one does not will to cause death; one’s inability to impede it is merely accepted.  The decisions should be made by the patient if he is competent and able, or by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

 It is morally acceptable to forgo medical interventions when they cause undue burden to patients

Interventions are not morally obliged when they cause undue burden to the patient and the family. For example, an 80-year-old cancer patient chooses not to pursue a standard treatment procedure because it is lengthy, costly, and painful for his age.  A person with end-stage renal failure chooses to discontinue dialysis because he is bed-bound and lacks the energy to continue treatments and to relate with others.  A person chooses not to pursue a major surgical procedure because the intervention entails financial hardship that would require selling a family’s home or exhausting the funds designated for his children’s education and day-to-day expenses.[4]

In all the situations presented above, the patient and family, under the guidance of a physician, can determine whether a treatment is morally obliged.[5]   The patient and/or surrogate must make a conscientious judgment about the benefits and burdens involved in a given treatment in order to determine what constitutes ordinary and extraordinary care in their particular case.  The physician is involved in this process since patients and family members depend on his expertise, knowledge, and skills in determining the benefits and risks of certain procedures in relation to the prognosis and overall condition of the patient.

Patients or their surrogates do not will or intent to cause death if they chose to forego medical interventions that have little chance of success or are dangerous and painful. The omission allows death to takes its natural course, even though death occurs earlier than if aggressive interventions had been carried out.

The application of the principle of ordinary and extraordinary means must be carefully assessed

The benefits and the burdens of each treatment/procedure must be assessed for its merit. In Theological sense, an extraordinary medical procedure may not necessarily be an extraordinary means of conserving life.  The same is true with ordinary medical procedures.  For instance, we cannot simply say that ventilators are always as an extraordinary procedure, or glucose drip is always considered ordinary.  A ventilator, which is often used to critically-ill patients may be ordinary when used to a patient who has great chances for recovery.  Ventilators are sometimes indicated for a few days in some cases to allow a patient to recover.  Consider for example a young person who ingested a caustic substance who is placed on a ventilator because of breathing difficulty.  The ventilator is placed as a temporary relief until this person is able to breathe on his own after a certain period of time.  The ventilator, in this case, is considered as a bridge to recovery.

There are some interventions that look like simple treatments but becomes extraordinary if applied for certain patients. Glucose, given intravenously, which is usually an ordinary intervention given to diabetic patients with an extreme hypoglycemic episode will become extraordinary for a comatose ninety-five-year-old with cardiopulmonary and renal complications. An antibiotic is an ordinary measure to treat infection, but it may become extraordinary for a person who is imminently dying of cancer and other serious conditions.[6]

From these examples, we can conclude that what is a morally ordinary treatment for a person with a good chance of recovery becomes morally extraordinary for one with a little chance to live.[7]  Thus the application of the principle of ordinary and extraordinary means requires a conscientious moral and professional judgment.  The Ethical and Religious Directives says that “The well being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology. Therapeutic procedures that are likely to cause harm or undesirable side-effects can be judged only by a proportionate benefit to the patient (No.32).

In an event that there are no other sufficient remedies, the Church through the Congregation for the Doctrine of Faith on the Document titled Declaration on Euthanasia, says that:

It is permitted, with the patient’s consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity. It is also permitted, with the patient’s consent, to interrupt these means, where the results fall short of expectations.  But for such decision to be made, account will have to be taken of teh raesonable wishes of teh patient and teh patient’s family, as also of the advice of teh doctors who are specially competent in teh matter. (8)

 There are important questions to ask in forgoing burdensome treatments

Fr. Kevin O’ Rourke offers guidance by raising important questions to be used as a tool in determining the removal of burdensome treatments. These questions are: A. Is the fatal pathology present in the body of the patient? B. Does resisting the fatal pathology involve effective or ineffective treatment? C.  If the therapy is effective; does it impose an excessive burden now or in the future? and D. What is the intention of those who decide to remove the life support?[8]

The Church teachings support the use of ordinary means that do not involve undue burden or tremendous physical, psychological, and spiritual distress for oneself or another.  One does not need to seek all possible cures for a fatal condition if there is little hope that any of them would be successful. People make decisions about such treatments based on the individual’s subjective response.[9]

The ultimate question to ask is, does the intention to remove life support and other treatments are to cause death to the patient? If it does, this action would be unethical and morally wrong.  However, when the intention is to remove life support because it is ineffective, unbeneficial and burdensome, then it is to cease doing something futile. Hence, the act is morally permissible. In the latter case, we may remove the life support and other treatments except for those that keep the patient comfortable and free from pain.

The practical difficulties in applying the distinction between ordinary and extraordinary means to prolong life will always remain. Determining whether to allow oneself or a loved one to die will always be a complex and difficult decision to make.

When the removal of life support and other treatments becomes ethically necessary, the death of a loved one usually follows a natural act, an act of God. Death is not desired by those who remove life support in this situation.  We experience inner peace when we carefully follow the ethical ways of decision making. Family members often express relief and healing that death has removed the burden that their loved ones had experienced, not the relief that they are dead. [10]

Addressing the case of Mary

Going back to my story, Mary’s husband and family agreed to remove her life support after careful conversation with her physician, close family friends, and with me. They realized and accepted the fact that all possible remedies had been exhausted to save Mary. They did their very best to take back her life. They were resigned to discontinue any life-sustaining treatments. However, they asked if they could wait for two more days to give time for Mary’s sister and brother, who lived out-of-state to be with her when the ventilator would be pulled out.

In this case, it is not only acceptable but also compassionate to offer reasonable time and space to the family. This will enable them to emotionally and spiritually prepare for the removal of life support and eventually, for the patient’s death.  This may also help them heal and reconcile past emotional wounds or strained relationships.

Mary’s family was grateful for the precious days they were able to spend time with her and with each other. There was a tremendous sense of peace and healing. It was exactly on the 12th day of Mary’s confinement when all the expected family members arrived. It also happened to be Mary’s 53rd birthday.

The family requested me to be with them when the ventilator would be removed.  I arrived in the ICU with the family at the bedside. There was a cake prepared for Mary and they began singing happy birthday soon as I arrived. They also rendered her favorite song.  Each one was given a chance to speak and bid goodbye.  The sadness that echoed in the room was heart-wrenching.

After I said my final commendation and prayer, the husband went out to inform the nurses that they were ready to remove the life-support.  They immediately came and offered comforting words to the family. They administered medication and removed the tube. They continued to monitor Mary for pain and discomfort. Mary’s skin color gradually became pale. Mary’s heartbeat and respiration stopped within a few hours since the life support was removed.

While Mary’s life support was withdrawn when her death was imminent, Dr. David Kelly, a Catholic theologian, wrote that “Treatments are morally extraordinary when their burden outweighs benefits, and this does not necessarily require that the treatment itself causes actual harm or that the patient’s death is imminent.” (11) Dr. Kelly continued, “To claim that treatment can be morally extraordinary only when a person’s death is imminent, regardless of whatever the treatment is given, is to give biological life itself an absolute value that supersedes all other values.” (12)

 

________________________________
[1] Grattan T. Brown “Ordinary and Extraordinary Means” in Catholic Healthcare Ethics, A Manual for Practitioners, 16.

[2] Grattan T. Brown, 16.

[3] Kevin O ‘ Rourke, OP, A Primer for Healthcare Ethics: Essays for a Pluralistic Society 2nd ed, 100.

[4] Ibid,100.

[5] Matthew Lomanno, Catholic Healthcare Ethics: A Manual for Practitioners, 216.

[6] David Kelly, Medical Care at the End of Life: A Catholic Perspective. Washington DC: Georgetown University Press, 2007, 8.

[7] Ibid.

8  Declaration of Euthanasia, Sacred Congregation for the  Doctrine of Faith,  Chapter IV: Due Proportion in the Use of Remedies, available at http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html

[8] Fr. Kevin O’ Rourke, OP, (2000), A Primer for Healthcare Ethics: Essays for a Pluralistic Society, 2nd ed, Washington, DC: Georgetown University Press, p 95-102.

[9] National Catholic Bioethics Center, A Catholic Guide to End of Life Decisions

[10] Kevin O Rourke, A Primer for Healthcare Ethics: Essays for a Pluralistic Society 2nd ed, 101.

[11] David Kelly,  Medical Care at the End of Life: A Catholic Perspective. Washington DC: Georgetown University Press, 2007,103.

[12] David Kelly,  Medical Care at the End of Life: A Catholic Perspective. Washington DC: Georgetown University Press, 2007, 103.

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